Chandigarh

DF-I

CC/216/2023

PARMINDER KAUR - Complainant(s)

Versus

CARE HEALTH INSURANCE LIMITED - Opp.Party(s)

02 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/216/2023
Date of Institution	:	25/04/2023
Date of Decision	:	02/05/2024

 

Parminder Kaur, aged 57, resident of House No.3198, Sector 28D, Chandigarh 160002.

… Complainant

V E R S U S

1. Care Health Insurance Limited, through its Manager Director, Regd. Office : 5^th Floor, 19 Chawla House, Nehru Place, New Delhi 110019.
2. Care Health Insurance Limited, through its Manager, Corp. Office : Unit No.604-607, 6^th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana).
3. Care Health Insurance Limited, through its Manager, Service Branch : CHIL, SCO 56-57-58, 2^nd Floor, Sec 9D, Chandigarh 160017.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	None for complainant
	:	Sh. Raj K. Narang, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Ms.Parminder Kaur, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant had purchased a health Insurance Policy (Annexure C-1) from the OPs under the plan name “CARE” which was valid w.e.f. 27.3.2021 to 26.3.2024 (hereinafter referred to as “subject policy”) on payment of premium of ₹66,497/- with sum insured of ₹10.00 lacs.  At the time of obtaining the subject policy, complainant was healthy and free from any disease.  Unfortunately, complainant suffered from an extremely rare disease called ‘acute transverse myelitis’ where her lower body got disabled and became unresponsive. Immediately on 21.11.2021, complainant was admitted in the J.P. Hospital, Zirakpur (hereinafter referred to as “Treating Hospital”) where she remained admitted till 29.11.2021 and the copy of discharge summary is Annexure C-2. As per the insurance policy, hospitalisation expenses and post hospitalisation expenses for 60 days are covered for reimbursement. The complainant had lodged a claim of ₹1,63,473/- with the OPs, out of which they only approved an amount of ₹66,584/- and denied the amount of ₹96,889/- on account of physiotherapy, nursing and some other exclusions. As per mutual consent, understanding and exclusions, part of claim was withdrawn, however, approved amount of ₹66,584/- alongwith denied physiotherapy expenses of ₹24,000/- were rightfully claimed.  Approvals and physiotherapy invoices are Annexure C-3.  Averred that till date physiotherapy and proper nursing care is the only medicine available for the said disease across the world.  Though the amount of ₹66,584/- was approved by the OPs and process for credit was initiated, but, the same was reverted to the source account due to some issue in the complainant’s bank account. Thereafter the complainant issued a legal notice to the OPs, but, with no result. After that the complainant had also sent an email to the OPs, after which OPs further approved an amount of ₹1,865/- to the complainant.   In this manner, the aforesaid act of the OPs in approving only part claim amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of facts.  However, it is admitted that the complainant had obtained the subject policy Annexure 1 from the OP which was valid w.e.f. 27.3.2021 to 26.3.2024.  It is further alleged that the complainant had approached the OPs with a claim for hospitalisation w.e.f. 21.11.2021 to 29.11.2021 with the Treating Hospital and the OPs had approved the claim and released an amount of ₹61,854/- vide NEFT as per settlement letter (Annexure 2) and ₹2,865/- vide NEFT as per settlement letter (Annexure 3). OPs had also initiated another payment of ₹1,865/- for the post hospitalisation bills, but the same were returned due to blocked bank account of the complainant.  It is further alleged that even as per terms and conditions of the policy, home nursing staff charges are not payable.  The complainant had also submitted certain bills which were not in her name and the same were not payable and the details of the admissible amount and non-admissible amount are as under :-

Claim No.92053764 01-02-03	Amount	Non payable	Amount
Claim amount	171973	Patient name not mentioned on bill	20497
Total deduction	-94230	Patient name not mentioned on ambulance bill	2500
Admissible amount	77743	Nursing staff charge & physiotherapy charges (not ipd)	69314
Co-pay	0	Other patient bill	1100
Amount paid in occ-01	-61854	Reg charge	100
Amount in occ-02	-2865	Cotton	150
Amount paid in occ-03	1865 (returned back due to blocked bank account)	Wipes	180
Total payable amount	13024 (unable to pay due to blocked bank account)	Gauze swab	225
		Dettol	60
		Betadine	104
		Total deduction	94230
Total bills	21-11-2021
3500	29-11-2021
2500
3172

                    

19937	Patient name not mentioned
500	Ambulance charge
500	Ambulance charge
1100	Other patient bill
16992	Care taker & nursing charge
1000	Ambulance charge
500	Ambulance charge
1650
2200
300
1489
560	Patient name not mentioned
1501
20322	Nursing staff
1350
900
32000	Nursing staff
30000	Physiotherapy
30000	Physiotherapy

              It is further alleged that the claim of the complainant was approved by the OPs, which was covered under the terms & conditions of the subject policy, and disapproved, which was not payable as per the subject policy and the consumer complaint of the complainant, being false, is liable to be dismissed. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.

3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the OPs and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy (Annexure C-1) from OP-1, which was valid w.e.f. 27.3.2021 to 26.3.2024 covering her with sum insured of ₹10.00 lacs and the complainant/insured patient was admitted in the Treating Hospital from 21.11.2021 to 29.11.2021 and was diagnosed with transverse myelitis with paraplegia, as is also evident from the discharge summary (Annexure C-2) and out of the total claim, OPs had only partially approved the claim of ₹61,854/- ₹2,865/- and ₹1,865/- towards her hospitalisation and pre-hospitalisation expenses and disapproved the claim of ₹90,584/-, the case is reduced to a narrow compass as it is to be determined if OPs are unjustified in only partially allowing the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OPs are justified in settling the claim of the complainant partially and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the documentary evidence placed on record by them and the same is required to be scanned carefully to determine the real controversy between the parties.
   3. Annexure C-1 is copy of the subject policy which clearly indicates that the same was valid w.e.f. 27.3.2021 to 26.3.2024 and the complainant was insured with sum insured of ₹10.00 lacs. Annexure C-2 is copy of the discharge summary issued by the Treating Hospital which clearly indicates that the complainant remained admitted there w.e.f. 21.11.2021 to 29.11.2021 and she was diagnosed with transverse myelitis with paraplegia. Annexure 3 are copies of claim approval & settlement letters vide which the claim of the complainant was partially settled/approved for ₹61,854/- and ₹2,865/- respectively. 
   4. As per the case of the complainant, she is also entitled for the physiotherapy bills submitted by her with the OPs to the tune of ₹60,000/-, which was taken by her after her discharge from the hospital i.e. in the month of January and February 2022 and the same are annexed with Annexure C-3.  However, perusal of the subject policy indicates that the said charges are not covered under the policy and the OPs had rightly not approved the bills to the tune of ₹60,000/- as claimed by the complainant on account of physiotherapy.
   5. Similarly, other bills of the complainant have also not been approved by the OPs since the same were not found in the name of the complainant and the OPs have tendered the copies of such bills submitted by the complainant which are Ex.OP-4, OP-10 and OP-11, relating to medicines and Ex. OP-8 & OP-9 relating to ambulance charges. Ex.OP-5 to OP-7 are bills of nursing staff/care taker staff, which are also rightly not approved by the OPs, being not covered under the subject policy and the details of all such bills are given in para 4 of their written version, as also tabulated above.
   6. In view of the foregoing discussion, one thing is clear that the OPs have rightly not approved the part claim of the complainant as the same was not covered under the terms and conditions of the subject policy, and hence it is safe to hold that the complainant has failed to prove any deficiency in service or unfair trade practice on the part of OPs.
4. In the light of the aforesaid discussion, the present consumer complaint, being devoid of any merit, is hereby dismissed leaving the parties to bear their own costs.
5. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

02/05/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member